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Dermoneuromodulation Rev 03
Dermoneuromodulation Rev 03
Dermoneuromodulation
TABLE OF CONTENTS
Overview of Dermoneuromodulation .......................................................................................................... 4 Some interesting facts about skin and its innervation .................................................................................5 Some thoughts on Neurodynamics ...............................................................................................................5 About tunnel syndromes ...............................................................................................................................7 Overview of Cutaneous Innervation............................................................................................................. 9 Specifics of skin treatment ........................................................................................................................... 9 A Closer Look at Skin Dynamics ................................................................................................................... 10 Why skin stretch? ........................................................................................................................................... 11 HEAD AND NECK........................................................................................................................................... 12 OCCIPITAL NERVES: ................................................................................................................................. 12 DORSAL RAMI OF NECK .......................................................................................................................... 13 ANTERO-LATERAL SUPERFICIAL CERVICAL PLEXUS: ............................................................................ 14 SUPRACLAVICULAR NERVES: ................................................................................................................. 14 SPINAL NERVE ROOTS............................................................................................................................. 15 AXILLARY NERVES ................................................................................................................................... 16 NECK AND SHOULDER ................................................................................................................................. 17 ACCESSORY NERVE (relaxing traps) ...................................................................................................... 17 DORSAL SCAPULAR ................................................................................................................................. 18 SHOULDER AND ARM .................................................................................................................................. 19 LATERAL CUTANEOUS NERVES OF THE BODY WALL............................................................................ 19 SUBSCAPULAR NERVES ......................................................................................................................... 20 LATERAL PECTORAL NERVES .................................................................................................................. 21 MUSCULOCUTANEOUS NERVE .............................................................................................................. 21 SUPERFICIAL CERVICAL PLEXUS............................................................................................................. 22 SUPRASCAPULAR NERVE ........................................................................................................................ 22 SUPRASCAPULAR NERVE (cont.) ........................................................................................................... 23 SUPRASCAPULAR NERVE (cont.) Pencil technique ...........................................................................24 CUTANEOUS NERVES OF THE ARM ........................................................................................................ 25 AXILLARY NERVES ................................................................................................................................... 25 TREATING THE TRUNK ................................................................................................................................ 26 Treatment of dorsal rami: ....................................................................................................................... 27 Treatment with side bending: ................................................................................................................ 28 Treatment with arm raising: ................................................................................................................... 28 Treating the ribcage: .............................................................................................................................. 29 Treating the DCN with skin stretch of the arm ..................................................................................... 29
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PELVIS AND HIP ........................................................................................................................................... 30 SUBCOSTAL NERVES ............................................................................................................................... 31 LATERAL CUTANEOUS NERVE OF THE THIGH ....................................................................................... 31 INGUINAL LIGAMENT AREA .................................................................................................................... 32 FEMORAL ................................................................................................................................................. 32 ILIOINGUINAL NERVE ..............................................................................................................................33 OUTSIDE OF THE HIP ...............................................................................................................................33 OUTSIDE OF THIGH ................................................................................................................................. 34 SUPERIOR CLUNEAL NERVES ................................................................................................................ 34 OBTURATOR NERVE ................................................................................................................................35 PUDENDAL NERVE .................................................................................................................................. 36 KNEE ............................................................................................................................................................. 38 OBTURATOR NERVE ............................................................................................................................... 38 SAPHENOUS NERVE ............................................................................................................................... 39 PATELLAR PLEXUS.................................................................................................................................. 40 TIBIAL NERVE ........................................................................................................................................... 41 COMMON FIBULAR (PERONEAL) NERVE ............................................................................................... 41 POSTERIOR CUTANEOUS NERVE OF THIGH ..........................................................................................42 OUTSIDE OF THIGH ..................................................................................................................................42 LATERAL CUTANEOUS NERVE BY THE KNEE .........................................................................................42 LOWER LEG, ANKLE, HEEL .......................................................................................................................... 44 FIBULAR NERVES .................................................................................................................................... 45 PLANTAR NERVES ................................................................................................................................... 45 SOME IDEAS ON TAPING FOR DNM ........................................................................................................... 47 APPENDIX .................................................................................................................................................... 48 BIOLOGICAL RESPONSE OF PERIPHERAL NERVES TO LOADING: PATHOPHYSIOLOGY OF NERVE COMPRESSION SYNDROMES AND VIBRATION INDUCED NEUROPATHY ...................................... 48 REFERRED PAIN OF PERIPHERAL NERVE ORIGIN: ........................................................................... 49 THE "MYOFASCIAL PAIN" CONSTRUCT ............................................................................................ 50 ALTERNATIVE EXPLANATIONS FOR MPS PHENOMENA ..................................................................53 REFERENCES .......................................................................................................................................55
Dermoneuromodulation
Overview of Dermoneuromodulation
This treatment system addresses soft tissue dysfunction (i.e., tension patterns, palpable tightness in tissue) and tenderness in tissue as felt by the patient. The two often overlap, although they may not. I chose the term dermoneuromodulation as a way to avoid falling into conceptual traps and pitfalls re: other soft tissue methods. I think a good case could be made that all forms of manual therapy are neuromodulatory in their effects, and since no one takes the skin off a patient prior to treatment, all manual therapies are dermo as well. It has been noted clinically that successfully reducing peripheral pain where it can be found and verified by both practitioner and by patient, will improve clinical outcomes such as range of motion. Anecdotally, patients report reduced pain, greater ease of movement, better strength, and improved perception of themselves within their own physicality. A study is underway to test these outcomes and hopefully verify them objectively. The DNM system takes into account cutaneous nerves. A cadaver study has demonstrated the directional orientation of subcutaneous skin ligaments that convey neural structures to the most superficial outer layer of the arm, as shown below. Note a slight resemblance to rigging on a sailing ship.
Figure 1 Figure: Dissected nerves, colored, with labels placed near to them
The treatment rationale includes providing the nervous system with novel stimuli to assist it to function more easily and economically. Ordinary mechanical pain (from movement deficiency) becomes decreased, usually markedly. Follow up homework includes movement suggestions, but
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not usually any exercise as such. This approach is consistent with neurodynamic theory and pain theory. Some techniques are borrowed from the plethora that exists, but nothing has been retained in any sort of pure form. Many techniques are completely original. All techniques are suggestions only. Once you learn how to engage the nervous system and feel it self-correct, you will undoubtedly learn your own easiest ways to go about treating your patients with simple hands-on methods. So you may regard this manual like a set of training wheels.
Seriously, try avoiding these nerves that embed into the underside of skin. Do you think it is even possible? There are estimated to be 45 miles (72km.) of nerves in the human body (BodyWorlds exhibit).
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for clearing away of metabolic by-products 4. The vasculature to the neural structures itself benefits from movement. It will be slack and tortuous in some positions, in some zones, and on tension other places, depending on position. 5. The nervous system includes the brain, and the brain likes novel stimuli. All these concepts apply to the nervous system that is directly below the cutis/subcutis as much as they apply to the large nerves and spinal cord.
Dermoneuromodulation
REFERENCES:
1. 2. 3. Butler D; Sensitive Nervous System, Noigroup Publications, 2000 Pe ina MM, Krmpoti -Nemaini J, Markiewitz AD; Tunnel Syndromes: Peripheral Nerve Compression Syndromes, 3rd Ed.; CRC Press, 2001 Standring S; Grays Anatomy 39th Ed.
ONLINE:
1. 2. Dorko, B; Characteristics of Correction; http://www.barrettdorko.com/articles/characte.htm Melzack R; Pain and the neuromatrix in the brain; J Dent Educ. 65(12): 1378-1382 2001 http://www.jdentaled.org/cgi/content/abstract/65/12/1378
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3. 4.
Quintner JL, Cohen ML; Referred Pain of Peripheral Nerve Origin: an Alternative to the Myofacial Pain Construct; http://www.pain-education.com/100137.php Rempel D, Dahlin L, Lundborg G; Biological Response of Peripheral Nerves to Loading: Pathophysiology of Nerve Compression Syndromes and Vibration Induced Neuropathy; http://books.nap.edu/openbook.php?record_id=6431&page=98
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cutaneous twigs that convey through it are changed, which stimulates mechanoreceptors. This is proposed as a neurodynamic explanation for the effectiveness of the application. One can use positioning of various parts of the body to add another dimension of mechanoreceptive stimulation to the system being treated. One can combine skin stretch with positioning.
SKIN LAYER (CUTIS) SUBCUTANEOUS FAT (SUBCUTIS). NOTE CUTANEOUS TWIG ENCLOSED IN AND CONVEYED TO SKIN BY SKIN LIGAMENT ADVENTITIA NERVE, SUSPENDED BY ADVENTITIA ABOVE AND BELOW
MUSCLE Figure 3 This is a schematic of a cross section of a conceptual normal skin neurodynamic. One cutaneous twig is shown conveyed to skin via a skin ligament
Figure 4 : This is a schematic of differential of layers that may occur when an underlying layer is moved due to muscular contraction. Note mechanical distortion of the neural sleeve.
If there is muscle tension pulling on the suspension system from beneath, the nerve and the neural tunnel are pulled in the same direction under the skin, creating the usual hypoxic threat to the nociceptors. Could this situation be misconstrued as a trigger point? What good would direct pressure on something like this do? Why not relieve the hypoxia first, by pulling the skin into some direction of comfort? As soon as the skin is comfortable, the tenderness and palpable tightness vanishes as if it were never there. The tenderness can be right over an underlying nerve, large enough to palpate. Such a structure might feel like a cord or string under the skin. Such cords vanish easily when skin is stretched in a direction that pleases the brain. The real trick is to stay there, hold everything in the shut off position, until the whole system, peripheral and central, resets. This takes 2 to 5 minutes, usually.
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OCCIPITAL NERVES:
Figure 5
Figure 6
On assessment, the patient will usually have a lot of tenderness at points on the occipital ridge. They may or may not also have a headache. They may or may not have restricted chin tuck.
1. Patient is comfortably supine with neck in neutral (Figure 6.). 2. Slide palpating fingers gently in behind head/occipital ridge, find the nastiest sore spot, to be treated first. Keep a monitoring finger over the sore spot. It will feel tight and hard and usually tender to the patient. Do not press it, just touch it. 3. With your other hand, gather up skin on the opposite occipital protuberance, as if you were going to make a bit of a ponytail with it. Slowly. The skin will stretch in an infinite number of vectors all round the whole head. If it makes it easier, you can visualize the head as a balloon. 4. Go slowly. Let the patient's brain register what you are doing. Remember their scalp skin doesn't have the same density of receptors your fingertips do, so give their nervous system time to process your intervention. 5. At some point, your monitoring finger on the sore spot will register either a sudden or gradual softening. Use that information to stop moving, and just hold statically whatever you've gathered to that point. There you are, with a bunch of skin gathered up in one hand and a soft, less tender spot under the other finger. 6. Wait. After about 20 seconds, check with the patient to see if the spot feels more comfortable to them, by poking it a bit and asking them to give you sensory feedback. "How is the tenderness? Still as tender or any better?" Usually it's better, but wait in that position for another minute or two. Remember this pain, like all pain and brain function, especially hindbrain functional change, is a process through time, like all of nature, not a machine with an on-off switch. It takes time for a new pattern to establish itself. Time is what your patient
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needs from you. It's humbling, but the truth is that's ALL they really need from you, once you've got their layers lined back up with themselves comfortably. 7. After about two minutes, slowly let go. Press the spot again, carefully. It will most times feel "normal", i.e., perfectly homogenous with the rest of the tissue (to you) and not tender (to the patient). You will have successfully persuaded the patient's own brain to dismantle a nociceptive driver. Congratulations. One down and probably several more to go. 8. Move on to the next one. By now the patient is usually relaxed and their nervous system is eager to track moreinput from you. Clear the occipital ridge (see picture at right); usually about 4 spots will do it. The more lateral ones generally require being held in a (tiny) bit of extension and rotation. By tiny I mean one Figure 7 or two degrees off neutral. Movement will often be fuller after, particularly head-nod. If not, some activation of deep neck flexors will likely help; e.g., contract- relax.
While you're back there, you might treat these cutaneous nerves along the vertebrae of the neck. Simply superficially skin stretch longitudinally on each side, for a few minutes. One set of fingers holds the skin caudal at the CT junction, while the other set of fingers pulls the skin upward along the spinous processes.
Figure 8
NOTES:
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Figure 9
1. Go lightly. Go slowly. 2. Roll the patient's head gently to one side or the other, just a few degrees. Position the lateral borders of your hands on the skin of the neck, one hand along the lateral border of SCM, the other along the medial border of SCM. Let your hands sink gently into the skin, just far enough to get a
Figure 10
3.
4.
5.
6.
7.
When you feel sufficiently "glued" to the patient's skin, drag your hands in different directions. Specifically, pull the skin under the lateral border hand down toward the sternoclavicular notch. Pull the skin under the medial border hand upward toward the angle of the jaw. At the first tiny tug of resistance, stop moving and hold your (tiny amount of) skin tension. There should be no indentation of the tissue going on. Think of gently pulling the skim off heated milk by pulling it sideways. Wait. In about 30 seconds, you might feel a relaxation in the skin. The patient's brain is responding to your input. Now you can take up a bit more slack, just a bit. Hang in there for a couple minutes, then let go slowly. Now the side you treated should feel a lot "looser." Repeat on the other side.
Figure 11
SUPRACLAVICULAR NERVES:
These drape down from the cervical plexus over the clavicles over the upper chest wall. On assessment, the skin just inferior to the clavicles will feel tight. 1. Sit at the side of the patient. Lay the outside edge of one hand along the bottom edge of the
Figure 12
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clavicle, and lay the outside edge of the other hand along the top edge of the clavicle. Let your hands sink into, and glue onto the skin a bit. 2. Pull the skin below the clavicle toward you. Push the skin above the clavicle toward the sternoclavicular notch. 3. Hold for a few minutes. Let go slowly and retest; the skin above, below and over the clavicle should feel more yielding. Treat the other side too.
Figure 13
1. Carefully palpate for the transverse processes. Let your fingers stick to the skin. 2. Slide the skin up onto the anterior surface of the transverse processes, into the soft tissue, to gauge how slidey or tight the tissues are /skin is.
Figure 14
Treating:
1. Target the tighter of the two sides first, and put your monitoring fingers onto the most turgid bit you can feel. 2. With the opposite hand on the opposite side, gather skin layer and grasp it, gently and slowly pulling it into a bunch. 3. Soon you will feel the tissue under your monitoring hand yield and soften, as you displace the mesodermal part of the neck over toward it. 4. Check with your patient to ensure they are comfortable. 5. Hold for a few minutes. Take up any slack that presents itself. Figure 15 6. Treat both sides. 7. Retest for improved amplitude of side glide. 8. Definitely teach your patient how to explore their new neck movement. Teaching them to find and practice ideomotor movement is the most beneficial approach in my opinion.
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NOTES:
We are still focused on neck, but also, we want to minimize the amount of time spent changing position. So I recommend checking and treating something else while you still have your patient in supine, namely the axillary nerve. This properly belongs in the shoulder section, so youll see it there as well.
AXILLARY NERVES
These are directly from the brachial plexus, posterior cord. The axillary nerve swoops down behind the shoulder, has to get through a narrow quadrangular space through teres and triceps, then enters the arm from the posterior axilla to supply deltoid. It has a cutaneous branch called Upper Lateral Cutaneous Nerve of the Arm. Bend your patients arm up, humerus at 90, hand resting on the forehead. Palpate the posterior border of the axilla. On assessment, there will be a hard and/or tender point or band or cord in the vicinity. 1. Monitor tender spot with one hand. With the other hand grasping the forearm, roll the skin over the rest, in an outward direction (toward supination). 2. You might also find it useful to lift the whole arm directly up at the same time, toward the ceiling slightly. 3. As soon as you feel the spot soften, that will be the right place to hold the arm for a few minutes. 4. Release s-l-o-w-l-y. Now, you can have your patient sit up for a moment. Have another look at their range. It should be easier, especially head tilt, and rotation, but the shoulders may still look raised and have knots. Time to treat prone.
Figure 16
NOTES:
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Figure 17
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a more comfortable way to be, maybe a pillow under the bosom. whatever then try again. Don't give up. Once the cranky spot doesn't feel cranky anymore, to either you or her, hold her arm there and wait, about two minutes.
DORSAL SCAPULAR
1. Same position and handling, but this time, take the arm further into relative elevation and outwardly AND/OR inwardly rotate it. Both good. 2. You can monitor as shown in the picture, or along the side of the neck. 3. Feel free to improvise a bit, ask for feedback, let the patient tell you how they would like you to move the arm, how much, how long to hold it there. You might need to go into different angles, or up past neutral into the extension zone. Let it be as interactive as it needs to be. Once patients get a taste of what this is about they can guide you better.
Figure 18
NOTES:
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These techniques work well for all those rotator cuff pains that keep people from recovering all their rotation.
Treatment:
Figure 19
1. Ask the patient to leave their elbow pointing up toward the ceiling, and to rest their hand on their head somewhere, and to abdominally breathe. Explain to them what you plan to do.
Figure 20
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2. Place your hands softly onto the ribcage top and bottom. Give your hands a moment to stick to their skin. Waiting just a few seconds means you need to exert less force less deeply (more finesse). 3. Slowly stretch your hands apart, just enough to take up skin slack. Wait. Usually the patients system will provide you with more slack to take up after a little while. Take it up as it presents itself. Do not overstretch. 4. After a minute to two minutes, slowly let go, lift your hands away, and fold their arm back down straight along their body. Let the brachial plexus refresh itself. Then retest. Its not uncommon to gain 30 or 40 degrees of arm elevation, just with this simple intervention. If you do not get the expected huge increase in range, then look a bit closer at scapular movement and/or pec excursion. Serratus anterior may be entrapping the lateral cutaneous nerves up at the top, especially on gym attenders, or maybe the subscapular nerves could use some movement. Set up treatment as shown at right.
SUBSCAPULAR NERVES
Figure 21
1. Tell your patient what you want to do. Ask them to abdominally breathe. Place the heel of your hand comfortably along the lateral border of the scapula. 2. Slowly press it medially toward the other blade, taking up slack as it presents itself. Do NOT be in any hurry. If this takes 5 minutes, then spend 5 minutes. 3. It helps to use the supporting hand, up on the elbow, to pull some skin up the back of the upper arm toward the elbow. Always be thinking up new ways to move/slide cutaneous nerves, in this case, the posterior cutaneous nerve of the arm. 4. Sometimes you can feel the scapula start to slide easily all of a sudden. The patient will usually say something like, Ooh, that feels so good. Other times, this wont happen. It probably has less to do with your treatment and more to do with how well they can perceive their own body. Whatever. Do your best and move on.
NOTES:
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Treatment:
1.
2. 3.
Figure 22
4.
Explain what you want to do. Let the patients elbow lean against you. Take the full weight of the arm; ask them to give it to you. You can tuck their elbow under your own arm somewhere. Ask them to abdominally breathe and relax as much as possible. Grasp the whole anterior compartment of the axilla in two hands, and let your hands and their brain have a moment to say hello to each other. Then gently squeeze into it. Take your time. Take up slack as it presents itself. You are not just on a great big pec tendon, you are affecting some very sensitive and responsive neural tissue, including the intercostobrachial nerve cutaneous to the axilla. Give this lots of time, and when it feels like it cant lengthen anymore, let go slowly. Now on retest the arm should be able to go further.
MUSCULOCUTANEOUS NERVE
This nerve comes off the brachial plexus, pierces through coracobrachialis, supplies it, biceps and brachioradialis, then changes its name to lateral cutaneous nerve of the forearm. Treat the front of the shoulder if there still seems to be some tightness present.
Treatment:
Apply a light skin stretch to the front of the upper arm as shown at right.
Figure 23
NOTES:
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Treatment:
You wont really know if you are treating these or as above, musculocutaneous. The one (superficial) overlaps the other (deeper) so it hardly matters. Just get on the skin and stretch it gently.
Figure 24
SUPRASCAPULAR NERVE
On assessment, there will be a persistent tender place above the spine of the scapula, and pain on movement. This is the only nerve that requires its own unique treatment position, prone at the edge of the bed. Ask your patient to move over to the edge of the bed so that the arm can hand over the side instead of off the front end. This will mean the neck will need to be turned whichever direction is most comfortable is fine. Maybe you can place a towel roll to protect the neck from turning too far, and allow your patient more support for relaxation. You could also place a wedge under their hip to keep them from feeling they might roll off the bed, especially an obese patient.
Figure 26 Suprascapular nerve (top) Axillary nerve (bottom)
Treatment:
1. The arm hangs off the side of the bed. 2. With one hand palpate the cranky spot under or in the skin over supraspinatus. With the other, slowly lift the arm a bit out, and back, into abduction extension. About 45 degrees is good. Take the arm gently into external rotation (or internal, whichever works better). 3. The palpated spot should be starting to let go. Hold the arm in that position.
Figure 25
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4. To help it along, stretch the patient's skin gently down the radial side of the forearm, down by the wrist somewhere. The spot up top will let go completely. Hold that pose for a couple minutes.
Setup is the same as it was for the dorsal scapular nerve (see picture left), only the arm can be lower, and at a 45 angle forward/outward, and resting on your knee. 1. With one hand, palpate the infraspinatus zone, and select the area of worst tightness to monitor. 2. Place the other over the radial side of the forearm; roll the forearm into outward rotation until you feel things soften under the monitoring hand. It helps to pull the skin down over the forearm, which affects the lateral cutaneous nerve of the forearm. See if inward rotation is helpful. If so, use it too. 3. Feel free to make slight adjustments in your position, pressure, or angle, to take advantage of slack that will open up.
Figure 27
A variation as shown at right, will hopefully help take care of a pesky sore spot that is often found right at the medial superior tip of the scapula. This could be a dorsal cutaneous nerve of the T spine. Setup is the same as above, only this time the elbow is bent and the forearm is resting on your lap.
Figure 28
Dermoneuromodulation Treatment:
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1. Bend the elbow to 90 degrees and rest it on your knee. With one hand, use a light finger to palpate a very sharply tender sore spot right on the superior/medial corner of the scapula. Rest your finger there - do not aggravate the soreness by pressing it. 2. Grasp the arm just above the elbow, skin layer only, and slide it gently around the rest of the arm into internal rotation direction. 3. The rest of the arm will eventually follow but it seems important to let the patient's brain experience the lag time. Meanwhile, you can feel through your palpating finger some motion in the tissue layers. You'll know when to stop moving the arm - the sore spot will suddenly soften, and not hurt anymore.
Figure 29
1. Set up as at left, patient prone, arm by side. 2. Carefully press the eraser end of a new pencil into the space between the acromion process and lateral end of the clavicle. 3. Go as far as burying the whole eraser into the tissue but go slowly and wait for the patient to feel comfortable with each increment before adding another. 4. Sometimes it is helpful to pull the middle finger caudally at the same time. I dont know much about myo-osseus kinetic chains, but this might be one. For whatever reason, it helps the process along. If this was indeed your patients main restriction, when you recheck, they will have much improved range and decreased discomfort.
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When you have the patient prone with the arm hanging, you can get in around it on all sides and treat any of the cutaneous nerves in it,from any direction, using balloon technique. The picture to the right shows cutaneous branches of the radial nerve being treated. The left hand is monitoring for softening, and the right hand is doing the grasping. Feel free to explore the arm and treat what you might find. The elbow in particular is easy to treat in this position.
Figure 30
AXILLARY NERVES
These are directly from the brachial plexus, posterior cord. The axillary nerve swoops down behind the shoulder, has to get through a narrow quadrangular space through teres and triceps, then enters the arm from the posterior axilla to supply deltoid. It has a cutaneous branch called Upper Lateral Cutaneous Nerve of the Arm. Bend your patients arm up, humerus at 90, hand resting on the forehead. Palpate the posterior border of the axilla. On assessment, there will be a hard and/or tender point or band or cord in the vicinity.
1. Monitor tender spot with one hand. With the other hand grasping the forearm, roll the skin over the rest, in an outward direction (toward supination). 2. You might also find it useful to lift the whole arm directly up at the same time, toward the ceiling slightly. 3. As soon as you feel the spot soften, that will be the right place to hold the arm for a few minutes. 4. Release s-l-o-w-l-y.
Figure 31
NOTES:
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Figure 32
In the image below and above, note the 180 branch angle that not only the dorsal cutaneous but all the cutaneous nerves of the trunk must cope with as they surface, split, and bend backwards and forwards to run within the cutis/subcutis layer of the trunk.
Figure 33
The cutaneous branches surface through latissimus dorsi or through trapezius, or through their respective fascial attachments, neither of which are innervated from the back they cover, i.e., both of them completely bury the actual spinal muscles as they attach to the spinous processes. They then supply the skin layer. What do we suppose might happen if the lats are pulling one way, the traps another, and some other deeper layer of the back still another? Perhaps those dorsal roots become tugged from below, and end up tractioned from within, with mechanical deformation/hypoxia. Im not suggesting that all back pain is due to peripheral entrapment of the dorsal rami, but I am saying that a lot of back pain can be downregulated by a patients nervous system if these branches are attended to.
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3. Once your fingerprints have become attached to the skin, pull the skin on the opposite side of the spine from where you are monitoring, away from the spine at a 90 angle. 4. After a few minutes let go slowly. Move to the next spot.
Figure 34
5. Repeat steps 1-4 as necessary, over the thoracic, lumbar and sacral spine. It is useful for the superior cluneal nerves as well. The anterior cutaneous nerves from ventral roots can be treated this way as well. Ive found the exercises created by Tomas Hanna (founder of Somatics) useful for helping people gain increased awareness of how to help their trunks elongate, move, expand, and breathe.
Figure 36
Figure 35 Figure 37
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The patient is still prone. Just distal to the TL junction, one side will feel a lot harder/tighter than the other. 1. Place a wedge under the non-tight side, below the hip, effectively banking your patient up on the non-tight side. 2. Sit down on the wedged side. With one hand, palpate the tight area. With the other, take hold of the opposite side foot, by its lateral border.
3. Slowly load into the foot, pulling it toward you. It may not have to move much at all before you can feel an unloading happen under your palpating fingers. Once the back feels softer, wait. 4. If your patients foot gets uncomfortable, hook a finger over the outside of the end of the fibula, and pull down a bit of skin, keeping tension all the way up to the back while you unload the foot a little. The whole letting go process may take as long as 5 minutes.
5. When things feel done, slowly let go. Check the two sides. They will usually feel more even.
Patient is still prone. The zone between T6 and T12 has an extra layer, as trap overlaps lat (as if those dorsal cutaneous roots didnt have enough to contend with already). 1. Palpate and find out which side feels tighter and/or more tender. Stand on that side. 2. Monitor the tightness with one hand, lightly. With the other, slowly lift the patients arm up, elbow in extension, slowly. You may only have to lift a little, but with some people it will be a lot. Usually it will be somewhere between 45 and 60 degrees. When you feel something move under the palpating hand, thats your signal to stop lifting. Just hold the arm up at that level.
3. If you internally rotate the lifted arm, you will be tensioning trap. If you externally rotate it, you will be tensioning lat. Figure out which way works better in each case. Sometimes one way will, other times, for other patients, the other will. 4. Choose whichever way provides the patient with the most softening. Hold the arm in that position for about 2 minutes.
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This is the only time, in my experience, that adding a bit of pain is necessary for down regulating pain, necessary only because there is no kinder way to do it. Fortunately, we have something called DNIC (diffuse noxious inhibitory control) to explain the results. It is useful for people who look like they cannot get a good breath or expand easily. 1. Patient is supine. Place one hand behind the back, just to one side of the spinous process. Find a tender point there. This will be the most medial tip of a medial dorsal cutaneous nerve root. 2. With the other set of fingers, find a tender point along the edge of the breastbone, within the same segment of the body. This will be the medial potion of the anterior cutaneous branch. It will be tender. 3. Carefully press the two spots simultaneously, and hold. This will feel like pain to the patient, but they will downregulate rapidly. Only stay there for 15-30 seconds before moving on to the next segmental level. Their breathing does the mobilizing of the neural tunnel. 4. Patients usually feel that breathing is much easier after, that their ribcages feel more expanded, lighter.
Treating the DCN with skin stretch of the arm
The patient is supine. 1. Slide one hand behind their back, and feel the tissue beside the spine. Find what you want to treat. 2. With the other hand pick up the patients arm and fold it across them. Place your free hand on the back of their arm, and stretch the skin of its posterior aspect toward their elbow, until you feel the area you are palpating soften. Stay there, hold for at least two minutes. 3. The arm can be placed at literally any angle of a semicircle, from down along their side (for places in the upper back) to up over their ear (their head turned away) for lower back, whichever position feels the best. I find this particularly effective for upper back treatment.
These are just a few ways of treating the skin layer with and without added positioning. Discover your own ways. Adding wedges in and underneath the ribcage and or pelvis, sometimes both, will often facilitate your work.
NOTES:
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It never hurts to remind ourselves to explain to patients what we plan to do, and why, especially in this area of the body. Be sure they feel comfortable with being treated in this manner. Ask them to tell you immediately if they feel discomfort of any sort at any time, so that you can change your grip slightly, or modify the approach somehow. I think its best to treat from lateral to medial. We could look at the pelvis as a pair of large curved scapulas joined at the middle, but much less mobile, and as fused to the sacrum as it is possible to be without actually being fused. Cutaneous nerves have to get around this big bony fused part, coursing along the inside of it and around the outside of it, to get to the legs. Several long cutaneous nerves emerge from the low back, descend obliquely downward within the body wall to emerge at the pelvis on the sides or in front of the hips through the inguinal ligaments. There are numerous opportunities for entrapments, especially in a sedentary job, appy scars, leg crossing, etc. Well start in supine, and with the nerve that comes out T12 and travels cutaneously around the top of the iliac crests. Its called subcostal nerve (see p. 31).
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SUBCOSTAL NERVES
Usually one side is more affected than the other. The patient in standing will look like their pelvis tips forward on one side or backward on the other. This is defense, not defect. On supine assessment, there will be a real tight/hard spot at the top of one of the crests compared to the other. It may feel quite tender or just tight to the patient.
Treatment:
1. Stand on side opposite to target ilium. Put the bed to the correct height, put one foot up on the bed, place your patients legs up over your knee. (I often use a piece of yoga mat or carpet underlay to provide friction, promote more relaxation.) 2. Get comfortable. Reach over the patient and find, then monitor, the tender point. 3. Place the other hand across the bottom of the feet; slowly pull the feet away from the target side. The thighs will naturally roll slightly toward the target side. Turn both legs several degrees away from the target side, as if they were a large crank.
Figure 40
4. When the tender point stops being tender, and softens, wait in whatever position you are in for as long as it takes, for a change to occur. 5. You can finesse the process by pulling the skin over the lateral malleolus distally, and holding it there.
Figure 41
Dermoneuromodulation Treatment:
32
1. As shown at the right, locate and monitor the lateral cutaneous nerve. If its in trouble, it will feel hard and usually, but not always, tender. 2. Monitor it with one set of fingertips, and place the other hand on the skin at the front of the thigh about 2 inches distal. Let your fingerprints stick to the patients skin. 3. Once the contact is sufficient, traction the skin layer only, distal toward the knee, in line with the angle of the thigh.
Figure 42
4. The tender zone will soften and any tenderness will suddenly disappear. Wait. 5. Give it a few minutes, then slowly release.
FEMORAL
Treatment:
Treatment is exactly the same as for the lateral cutaneous nerve, just a few centimeters more medial.
Figure 44
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ILIOINGUINAL NERVE
Treatment
1. The tender spot will be high up in the groin, near or on the adductor attachment to the superior ramus. If you have a skeleton in the room, show them on the skeleton first where your hands are going to be placed, and why. Have a picture handy of where the nerve emerges. Get their consent once again. 2. Treatment is exactly the same as for the other inguinal cutaneous nerves, although for this one have the patients leg flexedabducted, and support the knee with your body so your patient can relax. The other leg is still over the bolster, and the foot of the leg being treated can rest its lateral border against the bolster.
Figure 45
There are a number of things you can do to treat in this position that will contribute to a good outcome. One of the simplest is balloon technique over the trochanter. There is a bursa under the skin in that area, and although I havent seen a picture of the neural plexus that innervates it, I have seen its vascular plexus at BodyWorlds. I expect theres a neural one too. In any case there are twigs from the lateral cutaneous nerve to deal with, and often the lateral most superior cluneal nerve will reachthis far.
Figure 46
Treatment:
1. Palpate the trochanter and the layers stretched over it. There will usually be a few sore spots either behind it or in front or both 2. Select a sore spot to treat, monitor it with one hand. 3. With the other, use the web of your hand to gather the skin in a horizontal version of the balloon technique, basically a large but non-nociceptive pinch. Gather the skin slowly. Wait
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for it to let you go further. Hold for a few minutes. Let go slowly. Quite large increases in range in the hip can be obtained in this simple way, sometimes, on some people that look like they might be ready for THR.
OUTSIDE OF THIGH
See the section on KNEE (p. 37)
These are long dorsal rami from the lumbar spine that drape obliquely down over the back of the iliac crests, through narrow fibrous tunnels. They are cutaneous to the skin over the buttocks, and can reach down as far as the trochanter on some people.
Figure 47
1. Palpate outside of pelvis superior to trochanter to locate any tender spots. 2. If you find one, monitor it, and lay the other hand flat along the outside of thigh. Wait for the skin on your hand to stick to the skin of the patients thigh.
Figure 48
3. Slowly drag the skin layer distally toward the knee, without pressing in. The tenderness should diminish easily in the tender spot. Hold a few minutes.
Treatment through levering:
1.
With one hand, monitor the tender spot. With the other, grasp the patients foot. Carefully lift it, and ask your patient to stay relaxed, to not try to help. As you lift the foot, the knees will stay together and the leg will go into internal rotation. Block the patients heel with your body and take the forefoot into adduction/inversion. When you feel a softening occur, hold in
2.
3.
Figure 49
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Do exactly the same thing again, but this time, take the foot into the opposite direction, abduction/inversion.
Figure 50
Treatment prone:
1.
Find and monitor the tender spot at or near the iliac crestto one side of the sacrum. Place the other hand on the trochanter on the same side as the tender spot. Lean straight down into the back of the hip, slowly. Take pauses. Wait for the patients body to let you proceed. Slowly release after a few minutes.
Figure 51
2.
3.
There are lots of other ways to get at these, so dont limit yourself to these few suggestions that there happen to be pictures for. Try holding the leg at different angles. Try skin stretch across the sacrum. Try whatever makes sense.
OBTURATOR NERVE
This nerve is deep and medial, descends through the pelvis and can become entrapped high up inside the pelvic floor. Lucky for us, it has a cutaneous patch on the medial thigh, just above the knee, where we can most easily get our hands on something it embeds into. On assessment in standing, when viewed from behind, the patients knee will look like it doesnt fully extend or the thigh internally rotate fully, compared to the other.
Treatment:
1. Patient is prone. Palpate the inner side of the thigh a few inches above the knee. It will feel as though a tight thin cable is suspended within the tissues. Often it will feel tender. 2. Sit down, get comfortable, lay your arms out along the length of the leg,
Figure 53 BALLOON TECHNIQUE VARIATION
Figure 52
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(see left) and with both hands grasp the skin over the inner thigh. 3. Slowly pull the skin up and around the thigh into internal rotation. 4. Stretch the skin you have in contact with your forearms, distally and proximally, simultaneously. 5. After a few minutes it will feel like the whole leg lengthens and softens. Let go slowly, then retest. It will feel like the tight thin cable is gone, and tenderness will be gone as well. Reassess in standing. Usually the knees will rotate more evenly. Other parts of the obturator nerve can be accessed through pelvic floor work.
PUDENDAL NERVE
Treating the pelvic floor and the nerves that can become entrapped within it may seem a bit daunting, but dont let any part of the body daunt you. Simply understand what you are about to do and why, provide clear explanation to the patient, and wait for permission. First, lets look at the neural component: the pudendal nerve supplies sensation to much of the pelvic floor. It is motor to the sphincters and to the autonomic aspects of the genitalia. People who have sensory disturbances, i.e., pain, burning, or paresthesias, that are worse with sitting, may well benefit from treatment. The internal rotators of the hip are buried in the pelvic floor as well, with their neural components. Right where the pudendal nerve comes out through Alcocks canal, just medial to the ischial tuberosity, is a good place to treat. Treatment can be successfully accomplished through a light layer of clothing.
Treatment:
Figure 54
1. This is for both male and female pelvic floors. You have already explained to the patient what you want to do and how, and have obtained their permission. Chart it. Make sure you have lots of time. You must not rush this. 2. Patient is supine, their knees bent up and supporting each other. Feet are flat on the table. You may want to place some pieces of yoga mat under the feet to keep them from sliding, and help your patient be able to relax, and not have to use any leg muscles to keep their knees up. Get gravity to do all the work whenever possible. 3. Take your time. Sit by the side of the patient, on the side youll be treating. Place one set of fingers on the skin of their ischial tuberosity, the other set on their iliac crest. 4. Let your fingers sink in for a little while. See if you can feel the patients breathing through your hands.
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5. When you are ready, straighten out your fingers and wrist. Slide the skin over the IT medially, without losing contact. Sink your fingers into the tissue just medial to the IT. Take pauses to let the tissue soften. Then proceed with a directly rostral pressure. 6. This is a sensitive area, and will take awhile to treat. Go slow and be sure you have your elbow lined up behind your forearm so you dont strain your wrist. The more you go slowly, the less work it will be. Get feedback from your patient. They will tend to unconsciously tighten in spite of themselves, so remind/ask them to relax again from time to time. 7. This does not have to be uncomfortable at all, if you and the patient are working as a team. Its also ok to take a rest, letting go completely. You can rest your and the patients body can reoxygenate. When you add pressure a second time, the nervous system will have likely learned to let your fingers in easier, and your patient will have learned to relax better. 8. This is clearly an indirect method rather than directly cutaneous, but it will accomplish the goal, i.e., will help slide the pudendal nerve further out of its tunnel entrapment. If more sophisticated pelvic floor work is required, refer out to someone with more advanced training and the scope to do internal work.
NOTES:
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KNEE
This large and often problematic area can be treated simply and effectively for pain and motor problems that may mimic orthopaedic problems, simply by removing possible neural confounding factors. Weve already looked at treating the outer thigh, and inner thigh. The knee itself is innervated from behind, by a branch of the obturator and genicular branches from the tibial.
OBTURATOR NERVE
This nerve is deep and medial, descends through the pelvis and can become entrapped high up inside the pelvic floor. Lucky for us, it has a cutaneous patch on the medial thigh, just above the knee, where we can most easily get our hands on something it embeds into. On assessment in standing, when viewed from behind, the patients knee will look like it doesnt fully extend or the thigh internally rotate fully, compared to the other.
Treatment:
1.
Patient is prone. Palpate the inner side of the thigh a few inches above the knee. It will feel as though a tight thin cable is suspended within the tissues. Often it will feel tender. Sit down, get comfortable, lay your arms out along the length of the leg, (see left) and with both hands grasp the skin over the inner thigh.
2.
Figure 56
3. Slowly pull the skin up and around the thigh into internal rotation. 4. Stretch the skin you have in contact with your forearms, distally and proximally, simultaneously. 5. After a few minutes it will feel like the whole leg lengthens and softens. Let go slowly, then retest. It will feel like the tight thin cable is gone, and tenderness will be gone as well. Reassess in standing. Usually the knees will rotate more evenly.
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SAPHENOUS NERVE
This long and extensively branched nerve that stems from the femoral, supplies the skin over the medial side of the knee picking up where obturator leaves off. It extends into the lower leg, giving off an infrapatellar branch that swings laterally. It reaches all the way to the medial foot, supplying skin (see below). The main nerve can be treated much the same way as the obturator, in prone, with hands placed lower. The tender spot is usually over the medial knee joint. It can be treated in supine too if you prefer. The actual patellar plexus and infrapatellar branch can be treated together (see further on).
Figure 57
Figure 58 TOTAL CUTANEOUS DISTRIBUTION OF FEMORAL NERVE SAPHENOUS BRANCH MOST MEDIAL AND DISTAL
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PATELLAR PLEXUS
The pictures to the right show the saphenous nerve, cutaneous to the medial knee and lower leg.
The picture below shows more of the contributors to the patellar plexus, namely the intermediate cutaneous nerve of the thigh, also from femoral nerve.
Figure 60 Figure 59
Treatment:
1.
Palpate carefully around the patella. Note any spots that feel tight or tender. Choose one of them to treat. Monitor with one finger, and with the other hand use the patella itself as a small lever or crow bar, pressing down on its opposite side, slowly. When you feel softening under the monitoring finger, hold for a few minutes.
2.
Figure 61
NOTES:
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TIBIAL NERVE
Treatment:
1. Patient is lying supine. Palpate back of the knee. 2. There will usually be a tender and or tight spot just below the crease, medial side. Target that. 3. Keep a finger on that spot, and carefully bring the leg down off the edge of the bed (be sure to put some padding there), and let it rest on your knee. The patients knee will be in slight flexion. 4. Place your working hand on the front of the lower leg, near the ankle. Carefully press it medially and into a small bit of medial rotation at the same time, as if to gap the knee joint laterally, but you arent going to press hard enough; instead, soft tissue will be tensioned.
Figure 62 MEDIAL VIEW OF KNEE GENICULAR BRANCHES
5. The medial side of the lower leg will be pressed into the bed. Tender/tight spot will relax. Stay with it. After a few minutes, slowly let go, and put the patients leg back up on the bed. Upon checking, there should feel like the tissues are all more mobile.
Treatment:
1. 2.
Palpate tender and or tight spot over the top of the fibula. Monitor it while you perform a balloon technique with the other hand.
See Manual pages for Lower Leg, Ankle and Heel for the rest of the fibular nerve considerations.
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Figure 63
Figure 64
Apart from the usual ortho tests, you can spot tension in the outside part of the leg in standing, simply by looking. The patient will prefer a wide base. If you ask them to stand with their feet together, theyll often say they feel pain in the hips or pelvis somewhere. Maybe their pelvis will torque one way or another. On a prone patient, on palpation of the outer side of the thigh, one side will feel more tight than the other, or maybe both sides will feel tight. They might not even like to lay prone, because it hurts their back. If this is the case, place some blocks under their hips to lift them up a little. Help them relax so they can focus on their good sensations.
Dermoneuromodulation Treatment:
43
1. With one hand, palpate the outside off the leg. With the other, grasp the foot and bend the knee to about 90, or maybe a little more. Rotate the hip slightly, into inward rotation,by bringing the foot out of the sagittal plane. 2. Ask your patient repeatedly to tell you if they experience any knee discomfort throughout. Ive treated using this technique for years and have never had any problem with knees, because I check/treat the knees prior and am sure beforehand they can handle the forces Im about to apply. TIP: DO THE SAME.
Figure 65
Even so, its good practice to ask your patient to let you know if they are experiencing any discomfort at any time, during ANY technique, especially this one, where youll be adding considerable load. 3. Next, torque the foot, s-l-o-w-l-y, into either internal or external rotation, whichever feels like the best choice for that patient. Go slow so you can choose properly. Or else do both. After youve decided how to hold the foot, load some body weight down through the heel, straight down into the knee. I know it seems like sacrilege, but you will find that the overwhelming majority of people will find this pressure quite comfortable. Load in carefully, by stages, always checking with your patient for their comfort level, until and only until - you feel their leg relax and the ITB area soften. Then hold them there for a few minutes.
4.
Figure 66
5. When you are done, decompress, lift yourself off their foot, carefully bring their lower leg back up into sagittal plane, and lower the foot to the bed, straightening the leg slowly. When you re-palpate the outside of the thigh, it will feel much softer, as though you have wrung out a lot of water out of the tissues. Most likely the softness is due to a lot of reflexive softening of motor structures. In any case, now they might be able to keep those outsides softer with some attentive exercise.
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This is quite straightforward. With patient in either prone or supine position, you can balloon the leg anywhere along the length of it.
Figure 68
Figure 67 Figure 69
Using the heel as a lever is simple to do and mechanically affects any nerve in any container passing the ankle, including sural 1. Palpate the back of the leg. Find a tight and or tenderspot to monitor with one hand. 2. With the other, grasp the heel slowly, squeeze it, and turn the soft tissue around the calcaneus, slowly. 3. Patients usually really like this. Hold the tissue turned for as long as you can feel reactions going on. 4. Repeat in the opposite direction.
Figure 70
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FIBULAR NERVES
The outer aspect of the anterior leg and top of the foot are cutaneously innervated by these branches (see right). The deeper branch passes under the retinaculum overlying the anterior ankle.
Treatment:
1.
Balloon technique around the ankle and hindfoot works quite well for the more superficial branch.
1.
Position your patient in sitting, on the edge of the bed. You will sit on a low stool facing them. The foot NOT being treated can rest on a chair. Figure 71 Place the foot you are treating on your knee. Locate and monitor a tender spot in the anterior bend of the ankle a bit lateral to midline. Place the other hand firmly around the calcaneus. With your knee operating as a third hand, take the whole foot into some
2. 3. 4.
Figure 72
passive dorsiflexion. Externally or internally rotate the skin and outer tissues over the heel, whichever way works better to turn off the tenderness you are monitoring. 5. Hold for a few minutes. Release your grip slowly. This technique is recommended for tarsal tunnel syndrome as well.
PLANTAR NERVES
Treatment:
Plantar neural tunnels do well with heel twists and shearing types of maneuvers applied to the sides of the feet, or applied to plantar and dorsal surfaces in a circular manner
Figure 75
Figure 74
Figure 73
46
In general; 1. Skin on the front of the tibia seems to prefer to be stretched distally. 2. Skin on the front of the fibula likes to be stretched proximally. 3. On the back of the leg, the opposite applies: The skin down along the fibula prefers to be stretched caudally, and along the tibia, proximally. 4. The skin over the heel seems to prefer external rotation forces. But in also likes quite heavy inversion. 5. The skin on the front of the knee seems to prefer to be stretched down medially and up laterally. I expect these directional preferences likely have to do with the direction of skin ligaments/cutaneous neural twigs entering cutis/subcutis from below. Its useful to use stretchy tape in these same directions to continue DNM over the next few days following a treatment.
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Figure 76
Figure 77
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APPENDIX
1. These are pages are from an open access textbook, Work-Related Musculoskeletal Disorders: Report, Workshop Summary, and Workshop Papers (1999), Commission on Behavioral and Social Sciences and Education, online at the website for National Academies Press. http://books.nap.edu/openbook.php?record_id=6431&page=98
BIOLOGICAL RESPONSE OF PERIPHERAL NERVES TO LOADING: PATHOPHYSIOLOGY OF NERVE COMPRESSION SYNDROMES AND VIBRATION INDUCED NEUROPATHY
David Rempel, MD, MPH, Department of Medicine, Division of Occupational and Environmental Medicine, University of California, San Francisco and Lars Dahlin, MD, PhD, and Gran Lundborg, MD, PhD, Department of Hand Surgery, Malm University Hospital, Malm, Sweden
Introduction
Nerve compression syndromes involve peripheral nerve dysfunction due to localized microvascular interference and structural changes in the nerve or adjacent tissues. Although a well known example is compression of the median nerve at the wrist (e.g., carpal tunnel syndrome) other nerves are vulnerable (e.g., ulnar nerve at the wrist or elbow, spinal nerve roots at the vertebral foramen, etc.). When tissues are subjected to pressure, they deform and create pressure gradients, redistributing compressed tissue toward areas of lower pressure. Nerve compression syndromes usually occur at sites where the nerve passes through a tight tunnel formed by stiff tissue boundaries. The resultant confined space limits tissue movement and can lead to sustained pressure gradients. Based on case reports, space occupying lesions (e.g., lumbrical muscles, tumors, cysts, etc.) can cause nerve compression injury, as can conditions associated with the accumulation of fluid (edema) or extracellular matrix in soft tissues (e.g., pregnancy, congestive heart failure, acromegaly, myxedema hypothyroidism, muscle compartment syndromes etc.). Although nerve injuries related to vibration occur near the region of vibration exposure, they may be manifested at constriction sites. Other conditions, such as diabetes mellitus may increase the susceptibility of the nerve to compression. In addition, an inflammatory reaction may occur which may impair the normal gliding of the nerve. Basic knowledge of the microanatomy of the peripheral nerve and the neuron and their complex reactions to compression are essential to understanding, preventing and treating nerve compression injuries.
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transsection a mushrooming effect is observed. There are no lymphatic vessels in the epineurial space, therefore problems occur when an edema is formed in the endoneurial space. Following such an edema the pressure in the fascicle may increase and rapidly interfere with the endoneurial microcirculation (Lundborg and Dahlin 1996). The epineurial vessels are more vulnerable than the endoneurial vessels to trauma and even to surgical handling of the nerve. The neuron itself is, as mentioned above, a unique cell with the cell body and the extending process (axon). The length of the axon may be 10 to 15,000 times the diameter of cell body. Therefore, there is a need for an intraneuronal transport system axonal transport where essential products are produced and constantly transported from the nerve cell body down the axon (anterograde transport), and disposal materials and trophic factors are also transported in the opposite direction (retrograde transport) (Grafstein and Forman 1980). The axonal transport consists of various components where fast axonal transport (up to around 410 mm per day) involves various enzymes, transmitter substance vesicles and glycoproteins and the various slow components (up to 30 mm per day) involve mainly cytoskeletal elements such as subunits of microtubules and neurofilaments. It should be noted that axonal transport is energy dependent and disturbances in axonal transport may be involved not only in the development of diabetic neuropathy but also in nerve compression injuries (Dahlin et al. 1986). Normal Gliding of Nerve Trunks Outside the peripheral nerve trunk there is a conjunctive like adventitia that permits an excursion of the nerve trunk that is a feature of normal nerve functioning during, for example, joint movements. Such an extraneural gliding surface together with the normally occurring sliding of fascicles against each other in deeper layers intraneural gliding surfaces make the normal gliding of the nerve possible. The median and ulnar nerve may glide 7.3 and 9.8 mm respectively during full elbow flexion and extension, and the extent of excursion of the nerve just proximal to the wrist is even more pronounced (14.5 and 13.8 mm respectively) (Wilgis and Murphy 1986). In relation to the flexor retinaculum the median nerve may move up to 9.6 mm during wrist flexion and to a slight degree in wrist extension but the nerve also moves during finger movements (Millesi et al. 1990).
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authors have recognized that there may be considerable clinical overlap between the two syndromes (12,13). In view of the controversial and complex nature of these pain syndromes, a critical analysis of the prevailing hypotheses is justified to clarify the situation. In this article, the hypothesis that pain arising from trigger areas within muscles is of primary myofascial origin is critically examined. It will be shown on epistemological, clinical, and pathophysiological grounds that the myofascial pain syndrome (MPS) construct is invalid and that the phenomena it purports to explain are better understood as secondary hyperalgesia of peripheral neural origin.
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effects have been noted. Unless muscle strains are severe (e.g.., complete tears) or associated with deep haematoma formation, recovery is complete. Sever distraction or contusion injuries are common in sport but no evidence has been presented that such well-defined acute injuries are antecedents of MPS. Furthermore, electromyography of painful muscles (22) and thermographic studies of the tissues overlying them (23) have not demonstrated abnormalities in TrPs. Muscle biopsy studies of TrPs have also been largely unrewarding in terms of muscle inflammation or damage. Perpetuation The chronicity of pain that follows the activation of a myofascial TrP has been explained by a feedback cycle maintained by bombardment of the central nervous system (CNS) by impulses from TrPs themselves: that is, they become selfperpetuating. However, remote lesions in joints or chronic visceral disease and dysfunction may also provide noxious input into this cycle, as may emotional stimuli, chronic infection, various metabolic disturbances, and even dietary deficiencies (14). As the painful muscles in MPS are electrically silent, the presence of muscle spasm that may reflect ectopic impulse formation seems most unlikely (22). Furthermore, the efferent arm of the proposed vicious cycle has been tested. Mense (24) found that gamma-motoneuron activity was diminished rather than increased in muscles with carrageenan-induced injury and concluded that the proposed vicious-circle models "have to be considered as working hypotheses rather than explanations of known mechanisms. Spread Spread of pain is attributed to latent TrPs being activated or to active myofascial TrPs "metastasizing" to sites within or outside of the pain-reference zone of the original TrP(s) (18). Travell (14) postulated a chain reaction whereby an everincreasing number of satellite TrPs come into being, causing complex overlapping patterns of pain. Reliability of TrP phenomena When blinded as to diagnosis, those expert in the field of MPS were able to detect active TrPs in only 18% of examinations of subjects with a MPS diagnosis (25). In the same study, expert assessments for taut bands and muscle twitch responses were also found to be unreliable. These findings call into question the internal validity of the construct. Treatment Inactivation of the TrP by physical and chemical means would be predicted if the TrP is indeed a site of primary hyperalgesia. However, reports of the efficacy of this approach are only anecdotal; inactivation has not been subjected to formal trial. Furthermore, the persistence of using the recommended approach in the face of clinical inefficacy, along with the continuing failure over time to reveal a reasonable anatomical or pathophysiological basis for so doing, is not only irrational but also fails to acknowledge powerful placebo effects (26) and the wider psychosocial context of chronic pain (27). Objections to MPS construct The definition of MPS incorporates a preferred hypothesis of causation. This logical error has resulted in a system of diagnosis and treatment that has become popular but remains entirely anecdotal. Moreover, the proposition that myofascial pain and TrPs are intimately related constitutes circular reasoning: that is, by virtue of its form this proposition must always be true (Table 1). In their efforts to preserve the centrality of the myofascial TrP, myofascial pain theorists have al- lowed the number and nature of predisposing, precipitating, and perpetuating factors to be open-ended and to encompass the full spectrum of aetiology, including the untestable psychogenic level. (16,17). This serves only to perpetuate the circularity of the reasoning. Perhaps in an attempt to provide external validity, researchers have said that TrPs arise from muscle damage, despite electrical silence and the lack of histological or biochemical evidence. Furthermore, there is neither support from an animal experimental model (24) nor from studies of human muscle injury (21). Trigger points are nonetheless said to be maintained via the CNS, not only by their own activity but also by a legion of processes associated with afferent neural input. Spread of pain is attributed to the activation of latent TrPs or to the metastasis of TrPs. This teleological argument is physiologically unsound. Taken together, the tenets of the MPS construct arise out of circular reasoning, which should condemn MPS as epistemologically unacceptable."MYOFASCIAL PAIN" VERSUS PERIPHERAL NEURAL PAIN The argument that follows explores a putative relationship between "myofascial pain" and pain of peripheral neural origin. We show that the explanation for peripheral neural involvement in MPS, which depends on nerve compression by "taut bands," is speculative and unconvincing. Application of current concepts of the physiology of nociception can lead to an alternate construct. Differential diagnosis of MPS The differential diagnosis of myofascial pain, as proposed (14,16), includes a variety of painful and somewhat loosely defined neurological conditions such as thoracic outlet syndrome (28), radiculopathies, and polyneuropathies. Their differentiation from myofascial pain is said to be facilitated by the presence of accompanying neurological deficits (particularly those matching a peripheral nerve or root distribution) and electrodiagnostic abnormalities (15). Although a
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fundamental distinction has been made between TrP pain (deep and aching) and pain of peripheral neural origin (prickling, tingling, and numbing), Dalton and Jull (29) were not able to distinguish between somatogenic and neurogenic cervicobrachial pain when they relied solely on the characteristics of pain. Moreover, peripheral neural pain can occur without neurological deficit (30) and without conventional electrodiagnostic abnormality (31). By contrast, when neurological deficit (often accompanied by electrodiagnostic abnormality) accompanies MPS, it has been ascribed to peripheral nerve entrapment by the taut band containing the TrP (16,19). The taut band is said to cause an overall shortening of the involved muscle, which then, in turn, can lead to a "secondary" nerve entrapment syndrome (32). The dual propositions that neurogenic mechanisms can activate myofascial TrPs and that myofascial TrPs can cause neurogenic pain add up to a circular argument. Furthermore, the neurological literature does not include the TrP taut band as a recognized anatomical cause of entrapment neuropathy (33,34). However, on clinical grounds alone, there appears to be an intimate relationship between MPS and defined neuropathology. This relationship is worth exploring in terms of current understanding of nociceptive mechanisms. Characteristics of myofascial pain The pain attributed to myofascial TrPs is described as deep, dull, and aching, varying in intensity from mild to severe and occurring either at rest or only on motion (Table 2). These are the characteristics of deep somatic pain. By the 1930s, it had been long known that pain arising in deeply situated joints was often referred to anatomically distant structures. The seminal clinical experiments carried out by Lewis (35) and Keligren (36) convincingly demonstrated the same phenomenon for pain arising in other deep musculoskeletal tissues, such as muscles, ligaments, and periosteum. According to Kellgren (36), "The diffuse pain from a given muscle is always distributed within certain regions, though the distribution within these limits varies from individual to individual, and according to the part of the muscle stimulated" and "pain from muscle may be confused with pain arising from other deep structures such as joints and testis." Some caution is therefore necessary before a mechanically provoked pain response is attributed to a particular structure or structures. Afferents from muscles that are the sites of referred pain and tenderness are the very ones that converge centrally onto spinal neurones that could be involved in processing information from a region of deep damage, thus leading to central summation effects (37). Vasoconstriction, hypoesthesia, dermographia, and hyperhidrosis have been observed in the skin overlying a region of deep pain. These phenomena appear to be reflexly induced concomitants of somatic referred pain (38). Peripheral neural pain The connective tissues of human peripheral nerves are well-innervated. They derive their nerve supply from axons within the nerve and from fibres accompanying the extrinsic vessels that provide its nutrition (39). As well as regulating intraneural microcirculation, this intrinsic nerve system, the nervi nervorum, is thought to have a nociceptive function (40). Two types of pain, present singly or in combination, have been described in patients with peripheral neuropathy: "nerve trunk pain" and "dysesthetic pain" (41). The former pain has been described as aching, knifelike, or tender, whereas the latter has been described as burning, tingling, searing, crawling, drawing, or electric. Nerve trunk pain is therefore indistinguishable from pain described as myofascial (see Table 2). Nerve trunk pain has been attributed to increased activity in mechanically or chemically sensitized nociceptors within the nerve sheath, while dysesthetic pain has been attributed to damaged nociceptive afferent axons themselves. Nerve trunk pain characteristically follows the course of the involved nerve, which is found to be tender, whereas dysesthetic pain is felt in its peripheral sensory distribution (41). However, when pain of nerve origin is severe, it can be felt in regions outside the sensory distribution of the particular nerve (33,34). Peripheral neural pain may be associated with neurological deficit, but it can be accompanied by a hyperaesthetic syndrome, which includes both allodynia (pain due to a normally non-painful stimulus) and hyperalgesia (an increased response to a normally painful stimulus) (42-44). The term peripheral neuropathic pain has recently been suggested to embrace the combination of positive and negative symptoms in patients in whom pain is due to pathological changes or dysfunction in peripheral nerves or nerve roots (45). Pain with the characteristics of "nerve trunk pain" has been described by patients with irritative cervical (46) and lumbar (47) radicular lesions, with brachial neuropathy (40), and following peripheral nerve injury (48). Most nerve pain syndromes commence with symptoms more in keeping with an irritative than a destructive process (49,50). Local tenderness is commonly found over nerve trunks at sites of entrapment or metabolic insult; this tenderness has been attributed to sensitization of free nerve endings within neural connective tissue (nervi nervorum) (40). Such specific tender points over peripheral nerves, palpation of which could cause distant pain, was reported over a century ago (51). It has recently been suggested that radiating pain and other sensory phenomena could originate from ectopic neural pacemaker nodules formed at a site of entrapment (52). Tenderness has also been noted over motor bands (zone of innervation) and muscles in association with cervical and lumbar radicular pain without gross physical signs of denervation (53). Neuropathic pain states are frequently accompanied by abnormalities in functioning of the sympathetic nervous system (54). Referred neural pain
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lntraneural stimulation of muscle fascicles within the median and ulnar nerve trunks of normal volunteers has been shown to refer pain both distally to muscles within the innervation territories of each nerve, and proximally to deep structures (muscle and bone) in segmentally related regions outside the innervation territory of each nerve (55,56). Recounting his personal and clinical experience, Ochoa (57) described both local elbow pain and referral of pain into the ipsilateral scapular region following mechanical stimulation of an entrapped ulnar nerve at the elbow. In his own and the other cases, none of the distal symptomatology typical of ulnar neuropathy was present. Thus, peripheral neural tissue is a rich source of local and potential referred pain. Anatomical concordance of myofascial TrPs and peripheral nerves Some TrPs said to be myofascial could be situated in an adjacent hyperalgesic nerve trunk. For example, the discrete upper-limb pain syndromes attributed to TrPs in the middle finger extensor, the extensor carpi radialis, and the supinator muscles can equally be attributed to TrPs in the radial or posterior interosseous nerve trunks. The TrP said to be situated in the pronator teres muscle coincides with the median nerve, and the pain projected there from into the thenar muscles follows the course of the median nerve in the forearm. TrPs in the flexores digitorum referring pain into the hand may represent a tender compressed median nerve in the proximal forearm. MPSs in the shoulder girdle region may represent entrapment of the suprascapular nerve, the long thoracic nerve, the axillary nerve, and the dorsal scapular nerve, as the pain- reference zone of the TrPs follow the course of these nerves. In the lower limb, MPSs have been attributed to TrPs close to the sciatic, tibial, and superficial and deep peroneal nerves.
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TABLE 1. Problems with the MPS hypothesis Definition of syndrome incorporates hypothesis of causation. TrPs lack clinical reliability and validity. Predisposing, precipitating, and perpetuating factors are legion. Histological, biochemical, and electrical evidence of primary muscle pathology is lacking. There is no support for the MPS hypothesis from animal experimental models or human muscle injuries. Trigger points are an operational concept elevated to the status of theory by circular reasoning.
Clinical feature
Peripheral neural pain nerve trunk variety Deep aching Nerve trunk (local) Somatic referred
Sympathetic dysfunction
Electrodiagnostic abnormality
Usually absent
Usually absent
Therapeutic implications
Phenomena
Referred explanation
Hyperalgesia
Spread of pain
Chronicity
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